An emotional battle over which emergency physicians should be allowed to advertise their board certification in Texas shows no sign of a quick resolution.

After more than two hours of contentious testimony in June, the Texas Medical Board postponed a decision, deciding to tinker more with hard-fought wording in a key certification rule. “We’re not going to make everybody happy. We have no delusional thinking there,” said Board President Irwin E. Zeitler Jr., DO, after the board’s latest attempt at compromise wording failed to satisfy either faction.

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At stake is whether some 175 Texas emergency physicians will be allowed to continue advertising themselves as board certified by the American Board of Physician Specialties (ABPS), the certifying arm of Tampa, FL-based American Association of Physician Specialists (AAPS). Opponents argued that ABPS requirements for emergency medicine don’t rise to the level they called the “gold standard” set by the American Board of Medical Specialties (ABMS): completing a supervised three-year residency before candidates are allowed to sit for a board exam.

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“This really boils down to an argument between these two groups. They each want us to do what they want,” Dr. Zeitler said. “I would remind the board this is really a rule about advertising, and you have to do what is right for the citizens of Texas.”

AAPS, however, is strongly encouraging the Texas board to see the issue its way: Its lawyer, Joseph M. Nixon, sent the Texas Medical Board a letter on March 29 warning that “several legal issues will arise” if the board ultimately bars practice-track emergency physicians from advertising certification through ABPS and its subspecialty group, the Board of Certification in Emergency Medicine (BCEM). (Read Mr. Nixon’s letter to the Texas Medical Board on EM-News.com: http://bit.ly/NixonTMB.)

That’s no idle threat. The association filed suit against the New York Department of Health in December 2006, claiming the state agency illegally prohibited physicians certified by ABPS from advertising themselves as board certified. (http://bit.ly/NYdoh.) A federal district court granted New York summary judgment last September, finding “no genuine issue of material fact.” AAPS has appealed that decision. (Read the summary judgment on EM-News.com: http://bit.ly/NYJudgment.)

Emergency physicians opposing AAPS told the Texas Medical Board at its June meeting that ABPS’s alternate certification for emergency medicine misleads the public, calling it “disingenuous” and “fraudulent.”

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“The problem with the rule as it’s currently written is it creates apparent equivalency between those who did a supervised training program and those who have work experience,” said Patrick Crocker, DO, the chairman of the Texas Medical Board committee charged with hashing out a new certification rule. “You’ve got the American Board of Medical Specialists, the Board of Osteopathic Specialists, the Texas Medical Association, and everyone on [that] side saying, ‘It’s time that ends … for there to be a legitimate specialty of emergency medicine.’”

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Traditional certifying boards recognized by name in the Texas Medical Board rule — ABMS, the Bureau of Osteopathic Specialists, and the American Board of Oral and Maxillofacial Surgery — took notice, and soon the full board began holding a string of meetings bent on rewording rule 164.4. The rule’s latest proposed version, which met resistance on both sides of the warring factions in June, is set to undergo another round of revisions. While doctors with ABPS emergency medicine certification feared losing their right to advertise outright, doctors with ABMS board certification said the remaining vague language in the rule could open up new loopholes for ABPS to slip through.

Otto Marquez, MD, couched the issue for ABPS doctors as one of job security. “Forty percent of the emergency doctors in the state of Texas are not ABMS board [certified] in emergency medicine,” he said, adding that he has practiced emergency medicine in Dallas for 18 years. “My hospital advertises that I’m board certified [in emergency medicine]. The day the board changes that rule, I lose my job. It will affect my future patients. Leaving the rule the way it is benefits the patients of Texas. Changing this rule hurts the patients of Texas.”

Board President Dr. Zeitler called that logic “flawed” because the Texas Medical Board merely decides which doctors can advertise they are board certified. Each hospital’s medical staff, on the other hand, sets rules on which emergency doctors can practice at that hospital.

“While it seems like a simple advertising rule, I really believe we can be disenfranchised by it because we could be fired so easily,” countered Mike Fawcett, MD, who has ABPS certification in emergency medicine.

If the Texas Medical Board does not allow ABPS practice-track physicians to advertise their board certification, argued AAPS attorney Nixon, it should exclude physicians certified by the ABMS practice track before it was closed in 1988. “Today, approximately 45 percent of ABMS EM board certified physicians are ‘grandfathered,’ meaning they did not complete a[n] AGCME residency in emergency medicine,” Mr. Nixon wrote in a May 26 email to Ms. Robinson, the board’s executive director. During the board’s June meeting, he said, “[C]riticisms that are launched against ABPS’s pathway are valid if they are valid against 45 percent of the ABMS physicians.”

Debra G. Perina, MD, the president of the American Board of Emergency Medicine, said, however, that only 19 percent of the board’s current members were board certified through the practice track. “Eighty-one percent of ABEM’s 26,665 active diplomates completed a residency in emergency medicine,” she said.

The problem with AAPS’s argument, said Dr. Crocker, is that every new medical specialty, in order to establish itself, has an early but limited period in which doctors can become certified through a practice track. The difference, in the case of ABPS, is “they want to extend that forever.”

Angela Gardner, MD, the president of the American College of Emergency Physicians, said the Texas Medical Board is ultimately responsible for the health and welfare of the people of Texas, and setting criteria for board certification is a legitimate part of that duty. “I believe that the public expects a certain level of training when they hear the words ‘board certified,’” she said. “You simply cannot say that practicing and taking a board exam from an alternative board is equal to doing a residency in emergency medicine, not in the year 2010.”

–It should be noted that the ACEP President Dr. Angela Gardner herself and a significant number of the ACEP leadership have not finished an Emergency Medicine residency. If they claim that Texas ER physicians can not advertise themselves as “board certified” simply because they did not do an EM residency, then Dr. Gardner and the members of the ACEP leadership who did “primary care residencies” similar to the 40% of Texas ER physicians they are attempting to disenfranchise, should also not claim they are “board certified”. If we’re talking honesty and truthfulness, then it should go both ways.

– How did EM residency become a “gold standard” anyway, and what does that even mean? There are no studies demonstrating that EM residency trained ER docs have better outcomes than experienced ER physicians who did primary care residencies. In countries like Canada, both EM residency trained and Family Medicine physicians can be considered “board certified” in Emergency Medicine.

– Another fact glossed over in this article is that after more than 20 years, the EM residency track has failed to provide enough ER physicians to staff the nation’s ERs (Camargo 2008) at least till 2038, if ever. There is no other “legitimate specialty” where 45% of the services are provided by physicians who did not do residency/ fellowship training in that particular field 20 years after that specialty was introduced. This statistic clearly shows that Emergency Medicine is not like other “specialties” and

demonstrates the failure of the EM residency track approach in addressing the problem of providing Emergency services to meet the population’s rapidly growing demand.

Rather than a specialty, Emergency Medicine is really an “area/ field of expertise” like Primary Care where serivces are provided by physicians from multiple disciplines.

-ABPS attempts to address the Emergency Care staffing needs, particularly of rural populations who are underserved by ABEM certified physicians. If ABMS/ ACEP were truly concerned about protecting the citizens of Texas and other states, then they should worry more about providing access to good Emergency Care than protecting their turf and worrying about who calls themselves “board certified”.